Chapter 13 - Labor and Birth Process

In which manner is the fetal status best assessed during the active and transition stage of labor? Fetal heart rate at the peak of a contraction Fetal movement on the tocometer Fetal heart rate between contractions Fetal kicks over a one minute period

Fetal heart rate at the peak of a contraction Normal labor stresses the fetus by increasing intracranial pressure, decreasing heart rate and placental blood flow. Assessing the fetal heart rate during the peak of the contraction best communicates how the fetus is tolerating the labor. Fetal movement and fetal kicks can indicate that a fetus is compromised but that is a late sign of distress.

Which nursing action is a priority when the fetus is at the +4 station? Have a tocometer and a patient gown ready Have a blue bulb suction and an infant warmer ready Prepare for an immediate cesarean section Provide lubricating jelly and an internal monitor

Have a blue bulb suction and an infant warmer ready At the station +4, the fetus is being born. The priority nursing action is to have a blue bulb or suction device for airway clearance and an infant warmer ready. During admission the nurse will place a tocometer on the maternal stomach and have a gown ready. For checking effacement and dilation, the nurse will have a lubricant and possibly an internal monitor per health care provider orders. A cesarean section is not needed as the fetus has progressed through the birth canal.

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do? Notify the primary care provider of the problem. Increase the IV tocolytic to help in expulsion of the placenta. Do a vaginal exam to see if the placenta is stuck in the birth canal. Nothing. Normal time for stage three is 5 to 30 minutes.

Nothing. Normal time for stage three is 5 to 30 minutes. Following birth, the placenta is spontaneously expelled within 5 to 30 minutes, so there is no problem with this client. No further interventions are needed.

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: internal rotation, flexion, descent, extension, external rotation, expulsion. descent, flexion, external rotation, extension, internal rotation, expulsion. descent, flexion, internal rotation, extension, external rotation, expulsion. internal rotation, flexion, descent, extension, external rotation, expulsion.

descent, flexion, internal rotation, extension, external rotation, expulsion. The six cardinal movements of the fetus are descent, flexion, internal rotation, extension, external rotation, and expulsion.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? shoulders occiput brow buttocks

occiput With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." "It is flat and narrow, making it extremely difficult for the neonate to pass through." "It is rounded in shape and allows ample room for the neonate to fit through the passageway." "It is elongated, the width is roomy, but the length is narrow."

"It is rounded in shape and allows ample room for the neonate to fit through the passageway." The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid pelvis inlet allows the fetus room to pass through the dimensions of the bony passageway.

The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters? 5 to 7 8 to 10 3 to 4 0 to 2

8 to 10 The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic? A caput succedaneum Wrapping of the head Developmental delay A cephalohematoma

A cephalohematoma Blood collection under the scalp of the newborn from birth trauma is called a cephalohematoma. Instructions for care include simple observation of the area. The cephalohematoma will subside in a couple of weeks and may take a couple of months to completely go away. There is no brain damage associated with a cephalohematoma. A caput succedaneum is swelling, without blood collection, of the soft tissue of the head.

19. The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which of the following? A) Increment B) Acme C) Peak D) Decrement

Ans: A Feedback: Each contraction has three phases: increment or the buildup of the contraction; acme or the peak or highest intensity; and the decrement or relaxation of the uterine muscle fibers. The time from the onset to the highest intensity corresponds to the increment.

6. A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A) Latent phase of the first stage of labor B) Active phase of the first stage of labor C) Transition phase of the first stage of labor D) Pelvic phase of the second stage of labor

Ans: C Feedback: The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, contractions that are strong, painful, and frequent (every 1 to 2 minutes) and last 60 to 90 seconds, and irritability, apprehension, and feelings of loss of control. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The active phase is characterized by moderate to strong contractions every 2 to 5 minutes, cervical dilation of 4 to 7 cm and effacement of 40% to 80%, with the mother becoming intense and inwardly focused. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing.

A nulliparous client at 37 weeks gestation calls the labor and delivery unit to report she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions? Bloody mucus in the toilet once earlier in the day Contraction, regular and lasting longer and stronger Contractions, irregular, lasting 15 to 20 seconds Scant amount of thick, white vaginal discharge, no odor

Contraction, regular and lasting longer and stronger True labor contraction will progressively get worse and last longer. The pain will come to a point where the woman will not be able to walk or talk through the contractions. Irregular contractions, bloody show, and white vaginal discharge are normal for pregnancy but do not indicate true labor.

A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor? It helps the woman in labor to save energy. It facilitates vaginal examinations. It facilitates external belt adjustment. It helps to rotate fetus in a posterior position.

It helps to rotate fetus in a posterior position. The advantage of adopting a kneeling position during labor is that it helps to rotate the fetus in a posterior position. Facilitating vaginal examinations, facilitating external belt adjustment, and helping the woman in labor to save energy are advantages of the back-lying maternal position.

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? Radiates from the back to the front Slows when the woman changes position Occurs in an irregular pattern Lasts about 20 to 25 seconds

Radiates from the back to the front Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.

The nurse is preparing to teach a group of new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens? Oblique lie Breech Shoulder Transverse lie

Shoulder Shoulder presentations are the least likely to occur. They occur in less than 0.3% of all births. Approximately 97% of fetuses are in a cephalic presentation at the end of pregnancy. A longitudinal lie, in which the long axis of the fetus is parallel to the long axis of the mother, is the most common. When the fetus is in a transverse lie, the long axis of the fetus is perpendicular to the long axis of the woman. An oblique lie is in between the two.

A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? The contraction pains are 2 minutes apart and 1 minute in duration. The client reports back pain, and the cervix is effacing and dilating. The contraction pains have been present for 5 hours, and the patterns are regular. After walking for an hour, the contractions have not fully subsided.

The client reports back pain, and the cervix is effacing and dilating. True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.

The nurse is caring for a client at 39 weeks' gestation and whose fetal station is noted as a 0 (zero). The nurse is correct to document which? The client is fully effaced. The fetus is floating high in the pelvis. The fetus is in the true pelvis and engaged. The fetus has descended down the birth canal.

The fetus is in the true pelvis and engaged. When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings? The client is in active labor. The duration of the contractions is every 5 minutes. The frequency of the contractions is every 5 minutes. The client can be sent home.

The frequency of the contractions is every 5 minutes. Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? First Second Third Fourth

Third Stage three begins with the birth of the baby and ends with delivery of the placenta.

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? restitution descent engagement crowning

crowning Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? crowning effacement dilatation molding

effacement The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilatation refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.

The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? "She is in active labor; she is progressing at this point and we will keep you posted." "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." "She is still in early latent labor and has much too long to go to tell when she will give birth." "She is doing well and is in the second stage; it could be anytime now."

"She is in active labor; she is progressing at this point and we will keep you posted." At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign? "This means +1 and the baby is entering the true pelvis." "This is just a way of determining your progress in labor." "The presenting part is at the true pelvis and is engaged." "This indicates that you start labor within the next 24 hours."

"The presenting part is at the true pelvis and is engaged." Zero station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? -5 0 +1 +4

+4 As the fetus is being born, the station is +4. The fetus is floating and not engaged in the pelvis at -5. The fetus is at the level of the ischial spines and engaged at station 0. The fetus is progressing down the birth canal below the ischial spines at +1.

13. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? A) Frank B) Full C) Complete D) Footling

Ans: A Feedback: In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.

24. During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate? A) "It's difficult to predict how your labor will progress, but we'll be there for you the entire time." B) "Since this is your first pregnancy, you can estimate it will be about 10 hours." C) "It will depend on how big the baby is when you go into labor." D) "Time isn't important; your health and the baby's health are key."

Ans: A Feedback: It is difficult to predict how a labor will progress and therefore equally difficult to determine how long a woman's labor will last. There is no way to estimate the likely strength and frequency of uterine contractions, the extent to which the cervix will soften and dilate, and how much the fetal head will mold to fit the birth canal. We cannot know beforehand whether the complex fetal rotations needed for an efficient labor will take place properly. All of these factors are unknowns when a woman starts labor. Telling the woman an approximate time would be inappropriate because there is no way to determine the length of labor. It is highly individualized. Although fetal size and maternal and fetal health are important considerations, these responses do not address the woman's concern.

2. Which of the following would indicate to the nurse that the placenta is separating? A) Uterus becomes globular B) Fetal head is at vaginal opening C) Umbilical cord shortens D) Mucous plug is expelled

Ans: A Feedback: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.

25. A nurse is describing how the fetus moves through the birth canal. Which of the following would the nurse identify as being most important in allowing the fetal head to move through the pelvis? A) Sutures B) Fontanelles C) Frontal bones D) Biparietal diameter

Ans: A Feedback: Sutures are important because they allow the cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis. Fontanelles are the intersections formed by the sutures. The frontal bones, along with the parietal and occipital bones are bones of the cranium that are soft and pliable. The biparietal diameter is an important diameter that can affect the birth process.

7. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth? A) Cesarean B) Vaginal C) Forceps-assisted D) Vacuum extraction

Ans: A Feedback: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.

8. Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A) Latent phase of the first stage B) Active phase of the first stage C) Transition phase of the first stage D) Perineal phase of the second stage

Ans: A Feedback: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, and contractions occurring every 1 to 2 minutes lasting 60 to 90 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother.

15. After teaching a group of students about the factors affecting the labor process, the instructor determines that the teaching was successful when the group identifies which of the following as a component of the true pelvis? (Select all that apply.) A) Pelvic inlet B) Cervix C) Mid pelvis D) Pelvic outlet E) Vagina F) Pelvic floor muscles

Ans: A, C, D Feedback: The true pelvis is made up of three planes: the pelvic inlet, mid pelvis, and pelvic outlet. The cervix, vagina, and pelvic floor muscles are the soft tissues of the passageway.

23. A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which of the following would the nurse most likely include when discussing measures to promote coping for a positive labor experience? (Select all that apply.) A) Presence of a support partner B) View of birth as a stressor C) Low anxiety level D) Fear of loss of control E) Participation in a pregnancy exercise program

Ans: A, C, E Feedback: Numerous factors can affect a woman's coping ability during labor and birth. Having the presence and support of a valued partner during labor, engaging in exercise during pregnancy, viewing the birthing experience as a meaningful rather than stressful event, and a low anxiety level can promote a woman's ability to cope. Excessive anxiety may interfere with the labor progress, and fear of labor and loss of control may enhance pain perception, increasing the fear.

18. A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which of the following would the nurse most likely include? (Select all that apply.) A) Internal rotation B) Abduction C) Descent D) Pronation E) Flexion

Ans: A, C, E Feedback: The positional changes that occur as the fetus moves through the passageway are called the cardinal movements of labor and include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. The fetus does not undergo abduction or pronation.

3. When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics? A) Extent of opening to its widest diameter B) Degree of thinning C) Passage of the mucous plug D) Fetal presenting part

Ans: B Feedback: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show is a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

14. A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which of the following has most likely occurred? A) Cervical dilation B) Lightening C) Bloody show D) Braxton-Hicks contractions

Ans: B Feedback: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes as a result of the change in the uterus. The woman usually notes that her breathing is much easier. However, she may complain of increased pelvic pressure, cramping, and lower back pain. Although cervical dilation also may be occurring, it does not account for the woman's complaints. Bloody show refers to passage of the mucous plug that fills the cervical canal during pregnancy. It occurs with the onset of labor. Braxton-Hicks contractions increase in strength and frequency and aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix.

4. A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which of the following? A) Increased energy level with alternating strong and weak contractions B) Moderately strong contractions every 4 minutes, lasting about 1 minute C) Contractions noted in the front of abdomen that stop when she walks D) Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

Ans: B Feedback: Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

11. After teaching a group of students about the maternal bony pelvis, which statement by the group indicates that the teaching was successful? A) The bony pelvis plays a lesser role during labor than soft tissue. B) The pelvic outlet is associated with the true pelvis. C) The false pelvis lies below the imaginary linea terminalis. D) The false pelvis is the passageway through which the fetus travels.

Ans: B Feedback: The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is the more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.

12. A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as: A) +4 B) +2 C) 0 D) -2

Ans: D Feedback: When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.

9. A client is admitted to the labor and birthing suite in early labor. On review of her medical record, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted? A) Platypelloid B) Gynecoid C) Android D) Anthropoid

Ans: B Feedback: The most favorable pelvic shape for vaginal delivery is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth.

21. When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage? A) Regular contractions B) Cervical dilation C) Fetal movement through the birth canal D) Placental separation

Ans: B Feedback: The primary change occurring during the first stage of labor is progressive cervical dilation. Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

10. A woman telephones her health care provider and reports that her "water just broke." Which suggestion by the nurse would be most appropriate? A) "Call us back when you start having contractions." B) "Come to the clinic or emergency department for an evaluation." C) "Drink 3 to 4 glasses of water and lie down." D) "Come in as soon as you feel the urge to push."

Ans: B Feedback: When the amniotic sac ruptures, the barrier to infection is gone and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.

1. A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A) "I'm feeling contractions mostly in my back." B) "My contractions are about 6 minutes apart and regular." C) "The contractions slow down when I walk around." D) "If I try to talk to my partner during a contraction, I can't."

Ans: C Feedback: False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

16. A nurse is documenting fetal lie of a woman in labor. Which term would the nurse most likely use? A) Flexion B) Extension C) Longitudinal D) Cephalic

Ans: C Feedback: Fetal lie refers to the relationships of the long axis (spine) of the fetus to the long axis (spine) of the mother. There are two primary lies: longitudinal and transverse. Flexion and extension are terms used to describe fetal attitude. Cephalic is a term used to describe fetal presentation.

26. Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? A) -2 B) -1 C) 0 D) +1 .

Ans: C Feedback: Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spines, the distance is recorded as plus stations

17. The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which of the following is the presenting part? A) Occiput B) Face C) Buttocks D) Shoulder

Ans: C Feedback: The second letter denotes the presenting part which in this case is "S" or the sacrum or buttocks. The letter "O" would denote the occiput or vertex presentation. The letter "M" would denote the mentum (chin) or face presentation. The letter "A" would denote the acromion or shoulder presentation.

5. A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A) Supine B) Lithotomy C) Upright D) Knee-chest

Ans: C Feedback: The use of any upright position helps to reduce the length of labor. Research validates that nonmoving back-lying positions such as supine and lithotomy positions during labor are not healthy. The knee-chest position would assist in rotating the fetus in a posterior position.

20. A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction? A) Heart rate increase from 76 bpm to 90 bpm B) Blood pressure rise from 110/60 mm Hg to 120/74 C) White blood cell count of 12,000 cells/mm3 D) Respiratory rate of 10 breaths /minute

Ans: D Feedback: During labor, the mother experiences various physiologic responses including an increase in heart rate by 10 to 20 bpm, a rise in blood pressure by up to 35 mm Hg during a contraction, an increase in white blood cell count to 25,000 to 30,000 cells/mm3, perhaps as a result of tissue trauma, and an increase in respiratory rate with greater oxygen consumption due to the increase in metabolism. A drop in respiratory rate would be a cause for concern.

22. A nurse is caring for several women in labor. The nurse determines that which woman is in the transition phase of labor? A) Contractions every 5 minutes, cervical dilation 3 cm B) Contractions every 3 minutes, cervical dilation 5 cm C) Contractions every 21/2 minutes, cervical dilation 7 cm D) Contractions every 1 minute, cervical dilation 9 cm

Ans: D Feedback: The transition phase is characterized by strong contractions occurring every 1 to 2 minutes and cervical dilation from 8 to 10 cm. Contractions every 5 minutes with cervical dilation of 3 cm is typical of the latent phase. Contractions every 3 minutes with cervical dilation of 5 cm and contractions every 21/2 minutes with cervical dilation of 7 cm suggest the active phase of labor.

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions cause "ripening" of the cervix. Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions get closer together with activity.

Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.

A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation to occur? Bloody show Braxton Hicks contractions Lightening Cervical ripening and softening

Cervical ripening and softening The ripening and softening of the cervix which result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucous plug is expelled as a result of cervical softening and increased pressure of the presenting part.

A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation to occur? Cervical ripening and softening Braxton Hicks contractions Bloody show Lightening

Cervical ripening and softening The ripening and softening of the cervix which result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucous plug is expelled as a result of cervical softening and increased pressure of the presenting part.

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? Perineum False pelvis Cervix Uterus

Cervix The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? Expulsion Extension Flexion Engagement

Engagement The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? Fetal station Fetal attitude Fetal position Fetal size

Fetal position When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.

Which is the most important nursing assessment of the mother during the fourth stage of labor? The mother's psyche Blood pressure Hemorrhage Heart rate

Hemorrhage During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.

The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor? Transition phase Stage two Latent phase Stage three

Latent phase The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage two she may remain positive, but the work of labor is very intense.

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? Long axis of fetus is parallel to that of client. Long axis of fetus is at 45° to that of client. Long axis of fetus is at 60° to that of client. Long axis of fetus is perpendicular to that of client.

Long axis of fetus is perpendicular to that of client. If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus? LOA LOP ROA ROP

ROA The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.

The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2020 related to women in labor? Reduce the rate of cesarean births among low-risk births. Encourage women with previous cesareans to always have a cesarean. Ensure care during labor includes immunizations. Ensure all couples receive preconceptional genetic counseling.

Reduce the rate of cesarean births among low-risk births. Healthy People 2020 has two goals related to cesarean births in the United States. They are to reduce the rate of cesarean births among low-risk women and reduce the rate of cesarean births among women who have had a prior cesarean birth. Immunizations and genetic counseling are not associated with women in labor.

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? These contractions help in softening and ripening the cervix. These contractions increase the release of prostaglandins. These contractions increase oxytocin sensitivity. These contractions make maternal breathing easier.

These contractions help in softening and ripening the cervix. Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.

The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as: duration. intensity. frequency. peak.

frequency. Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? lying supine with legs in lithotomy stirrups squatting while holding her breath head elevated, grasping knees, breathing out lying on side, arms grasped on abdomen

head elevated, grasping knees, breathing out An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: start of labor. placenta previa. lightening. rupture of the membranes.

lightening. Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position. In primiparas, lightening can occur two weeks or more before labor begins; among multiparas, it may not occur until labor.

The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction? remain irregular with the same intensity cause discomfort over the top of uterus increase even if relaxing and taking a shower subside when walking around and use the lateral position

increase even if relaxing and taking a shower True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. increase in gastric emptying and pH increase in respiratory rate slight decrease in body temperature increase in blood pressure increase in heart rate

increase in heart rate increase in blood pressure increase in respiratory rate When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. increase in heart rate increase in blood pressure increase in respiratory rate slight decrease in body temperature increase in gastric emptying and pH

increase in heart rate increase in blood pressure increase in respiratory rate When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? increased risk of infection potential rapid birth of fetus potential placenta previa increased risk of breech presentation

increased risk of infection After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.

A pregnant woman at 37 weeks gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: occurring in the abdomen and groin. lasting about 30 seconds. occurring about every 5 minutes. relieved by walking.

occurring about every 5 minutes. The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the women evaluated, especially if she is less than 38 weeks pregnant.

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? reduction in length of the cervical canal restoration of blood flow to uterus and placenta effacement and dilation of the cervix shortening of the upper uterine segment

restoration of blood flow to uterus and placenta The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation of the cervix are other processes that occur during uterine contractions.

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? vertex breech cephalic shoulder

shoulder The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.

A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? transition phase latent phase active phase early phase

transition phase The woman is likely in transitional labor (first stage, transition phase) as evidenced by her increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation in the transition phase is 8 to 10 cm. The latent and early phase is the same phase of labor in the first stage and characterized by positive coping, mild contractions, and cervical dilation of 1 to 4 cm. The active phase is characterized by increased anxiety but cervical dilation of 4 to 7 cm.

During the second stage of labor, a woman is generally: very aware of activities immediately around her. no longer in need of a support person. turning inward to concentrate on body sensations. anxious to have people around her.

turning inward to concentrate on body sensations. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.